'17-'18 Healthy Lombard Partnership Application
Please complete this form by 2/4/17. Partnership payment can be completed at http://healthylombard.com on the right side of the page under "Donate" via PayPal. Membership fee is $100 for new members, and $75 for returning members. NOTE: For an additional $25, returning members may have an entry level table at the 2017 Fitness Fair. You may also mail a check to "Health Lombard c/o Jay Wojcik 128 South Third Ave. Lombard, IL 60148."

Those organizations participating in the Fitness Fair, separate fees will be listed on the next page of this form.

Membership Payment Type *
Required
Approved "in-kind" Service
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Organization Name *
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Department or Division
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Address *
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City *
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State *
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Zip *
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Website *
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Main Contact Person *
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Title *
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Office Phone *
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Cell Phone
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Email Address *
Your answer
Will your organization be participating in the 2017 Fitness Fair? *
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